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Cc <br /> STATE OF CALIFORNIA OCT 6 <br /> 1991 STATE WATER RESOURCES CONTROL BOARD <br /> SEP 2 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION= FPF "T"/ r w� � �, <br /> PLACER COUNTYTH <br /> Cil�.IIN N,♦ <br /> OMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> [- <br /> MARK ONLY 71 1 NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 171 2 INTERIM PERMIT F7 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> LUo Stf�ZL f oon PA2T CI- kk7 ei/02Q <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> g316- E 001-15fz1-00 Ra . Ma wA 49 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA LM f3! 36?Y <br /> ✓ BOX ��/ <br /> TO INDICATE l�CORPORATION �I INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 01239/// `��/ PHONE#WITH AREA GODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 76 -2Zs'Z <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME,-� � () 1 0 CARE OF ADDRESS INFORMATION <br /> G' <br /> MAILING OR STRE&ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> AS [O CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME T TE ZIP CODE KNEHO #WITH AREA CODE <br /> 9i�f A- _ 7 -1 14 1"-t <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA OF OWN CARE OF ADDRESS INFORMATION <br /> 2eC <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> aCORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME qrATE ZIP CODE HON #WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F474 - D 10 1 p 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT [=]6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER t PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATU APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> b ` ocvti /q— 4 <br /> LOCAL AGENCY USE 0 <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />